Please complete the form by printing this page or
downloading the PDF
file, attach
all supporting documents
and submit
entire nomination packet to:
Carol Cochran RN
2611 Pringle Rd. SE
c/o
Willamette ESD
Salem, OR. 97302
Email:
carol.cochran@wesd.org
Nomination Packet must be postmarked no later than: March 10, 2008
Candidate name and credentials: ______________________________________________
Candidate home address: ____________________________________________________
Telephone numbers: ________________________________________________________
Employers
Name: ___________________________________________________________
Employers Address: ________________________________________________________
Number of years
in present position: __________________________________________
Number
of years in school nursing: ____________________________________________
Grade levels served in current position… Pre K – 12th grade: ______________________
Number of students served: _________________________________________________
Position full time
(by Guideline standards)? Yes
No
Provider of direct nursing care in
practice? Yes No
Registered
Nurse? Yes No
Member of OSNA, current & previous 2
years Yes No
Nomination
submitted by: _________________________________________________
Address:
_______________________________________________________________
Date
Submitted: ___________________________
THANK YOU for your support!
Be sure to read the Guidelines and
Criteria before filling out this form.